- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.31 / $2,186.53 / $2,337.32
| Professional | | $1,671.31 | $2,186.53 | $2,337.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,950.00 / $4,950.00 / $7,425.00
| Professional | | $4,950.00 | $4,950.00 | $7,425.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,465.00 / $4,950.00 / $4,950.00
| Facility | | $3,465.00 | $4,950.00 | $4,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.57 / $1,507.95 / $2,513.25
| Professional | | $1,055.57 | $1,507.95 | $2,513.25 |